Severe Pre-eclampsia Case Discussion

Scenario: Patient presented with new onset elevated blood pressure in her 34 weeks of gestation. On thorough history; patient is having headaches, visual disturbances, and abdominal pain. Urine analysis showed proteinuria

 

» Clinical features of severe pre-eclampsia?

• Headache (most commonly the posterior part of the head is hypo perfused -> occipital headache)
• Visual changes (flashing lights, blurred vision, blindness)
• Mid epigastric pain (due to swelling of Glisson’s capsule of the liver)
• Signs: pulmonary edema, oliguria, cyanosis

 

» Risk factors?

• Nulliparity
• Age >40, or <18
• High BMI
• Prev pre-eclampsia
• FHx
• HTN, DM, GDM
• Vascular\connective tissue ds
• Thrombotic ds (antiphospholipid, thrombophilia)

 

» What tests to order?

• Labs:
  • CBC
  • Coagulation profile and platelet count (DIC, HELLP)
  • Peripheral smear (?): hemolysis (HELLP)
  • Liver enzymes: ALT\AST (HELLP)
  • Serum creatinine + uric acid
  • 24-hr urine collection for protein and Cr (or urine dipstick)

• Head CT, only if:
  • Sudden severe headache
  • Focal neurological deficits or altered mental status
  • Seizures w\ prolonged postictal state
  • Atypical presentation of pre-eclampsia

• Fetal wellbeing:
  • US, doppler, CTG monitoring, BPP

 

» Diagnostic criteria of severe pre-eclampsia? (>20 wks of gestation)

1. BP >160\110 (on 2 occasions + at least 6 hrs apart)
2. Proteinuria (>5 grams in a 24-hr collection)
3. Symptoms of severe features

 

» Management of severe pre-eclampsia?

1. Stabilize the pt (ABCs)
2. Admit to a specialist unit

If < 34 wks:

• Dexamethasone (4 doses of 6 mg every 12 hrs): to accelerate fetal lung maturity
• MgSo4 (4 g IV over 20 mins -> constant IV infusion -> continued 24 hrs post-partum)
• If signs of toxicity (↓ BP, HR, UO, reflexes, respiratory depression) -> give IV calcium gluconate
• Lower BP -> IV hydrazine or labetalol (aim for DBP of 90-100)
• Monitor for complications:
  • Eclampsia (seizures) -> give IV benzodiazepines
  • Vaginal bleeding (abruptio placenta)
  • Oliguria (renal insufficiency)
  • Fetal well-being

• If mother or fetus are uneatable -> deliver!

 

If > 34 wks:

• Give MgSo4 and continue 24-hrs post-partum
• Deliver:
  • If mom and fetus stable -> induce labor with IV oxytocin and amniotomy
  • If mom or fetus unstable -> C section

 

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